Tuberculous Osteomyelitis

September 14, 2005
Samer Alkhuja, MD

A 52-year-old man from Bangladesh had suffered from pleuritic pain for 1 week. He had never had tuberculosis and-except for being a cigarette smoker-had no notable medical history. The only remarkable findings were a temperature of 37.5°C (99.5°F) and anterior tenderness over the right lower rib cage. Laboratory test results were normal. A tuberculin test with 5 TU of purified protein derivative produced positive results, with a 15 × 17-mm induration.

A 52-year-old man from Bangladesh had suffered from pleuritic pain for 1 week. He had never had tuberculosis and-except for being a cigarette smoker-had no notable medical history. The only remarkable findings were a temperature of 37.5°C (99.5°F) and anterior tenderness over the right lower rib cage. Laboratory test results were normal. A tuberculin test with 5 TU of purified protein derivative produced positive results, with a 15 × 17-mm induration.

A chest film showed normal lung fields with a focal area of lucency in the ninth right rib. A pelvic film, taken to evaluate pubic pain that developed after the initial visit, showed a focal lucency and fracture (arrow) in the left inferior pubic ramus (A). A bone scan showed areas of increased activity in the left inferior pubic ramus (B) and in the ninth rib and the sternum (C, arrows).

Examination of specimens taken from segmental ninth rib resection and needle aspiration of the left inferior pubic ramus did not reveal any specific abnormalities, but cultures of the aspirate grew Mycobacterium tuberculosis. The diagnosis was tuberculous osteomyelitis.

Therapy was initiated with isoniazid, rifampin, ethambutol, and pyrazinamide. Clinical improvement was followed by resolution of the radiographic findings; there was no recurrence in the ensuing year.

Tuberculous osteomyelitis occurs infrequently, and its clinical onset is insidious, writes Dr Samer Alkhuja of Greenwich, Conn. The infection is of hematogenous origin, and pulmonary disease is often demonstrated. The radiographic findings are those of chronic, nonvirulent infection with eccentric areas of destruction; often, there is cortical erosion and an associated soft-tissue inflammation and swelling.1

When positive results are seen on a bone scan of a patient from a developing country, skeletal tuberculosis is a major consideration after malignancy is ruled out. Prescribe antituberculous agents while awaiting results of cultures. The osseous lesions usually respond satisfactorily to these drugs.

REFERENCES:1. Juhl JH, Crummy AB, eds. Essentials of Radiologic Imaging. Philadelphia: JB Lippincott Co; 1993:203-204.